Healthcare Provider Details

I. General information

NPI: 1548671902
Provider Name (Legal Business Name): HAILEY WOOLLEN GAVIGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 07/15/2024
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BLYTHE BLVD MEDICAL CENTER PLAZA SUITE 200
CHARLOTTE NC
28203-5866
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-381-8840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2020-02079
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number2020-02079
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number2020-02079
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: